Hi friends. The 320 is where I write — and talk — about nursing homes and numbers that tell stories. The following conversation has been lightly edited for clarity.
Eric Goldwein: So there’s a Venn diagram of people that spend half their waking hours thinking about nursing home policy, nursing home data, nursing home advocacy. That’s one circle. And in the other circle, there’s the people that are running 50 miles a week.
Now, in the intersection of those two circles are, I don’t know, a dozen people. I am one of them, and I’m lucky enough to be joined by another one of them, and that is Dr. Mike Wasserman. It’s good to have you on The 320 Podcast.
Mike Wasserman: It’s fun to be here, and I love the Venn diagram.
Eric: Are there others of us? There’s gotta be a few more…
Mike: Ironically, I do have some colleagues who I think at different points in their lives or careers might fill that, but probably not consistently.
Eric: Well, fitting to this Venn diagram theme, part one is gonna be nursing home focused, part two is gonna be athletics. You just did an Ironman. We’ll get into that.
You got on my radar in 2020. I was on a call and we were hearing about this former nursing home executive who was appearing on — I think you were on CNN. You were doing a little bit of the news tour in the peak of the pandemic.
This was not a good time for anyone. It was an especially rough time for nursing home residents. But now six years later, and this is just a broad question: thinking back to 2020, is this where you thought we would be?
Mike: You know, it’s interesting. I just came back from the PALTmed (Post-Acute and Long-Term Care) annual meeting, and Mark Parkinson (president of the American Health Care Association) gave a keynote showing a diagram of occupancy. And I remember when the occupancy of nursing homes just dropped like a rock.
Someone posted on Facebook or LinkedIn, “What do you think it will look like in the next three to five years?” And obviously, our memories are always a little fuzzy around these things, but I expected it to come back. I expected it would take a while.
And it turns out occupancy is literally almost at an all-time high, and only expected to grow, which actually wasn’t a difficult guess based on demographics.
Eric: What do you mean by that?
Mike: People tend to forget that prior to the baby boomers, there was something called the Silent Generation in the ’30s during the Depression. That Silent Generation — there was actually a decrease in births.
We’ve just come out of a timeframe where the number of 80-plus-year-olds kind of dropped a little bit in terms of growth, and that put some negative pressure on the long-term care occupancy market.
But we’re now fully into the baby boomers turning 80, and that is gonna have huge pressure on growth of 80 and above in the next 15 years, 20 years. And so just by that demographic imperative, and the fact that there will always be people who need an institutional level, a higher level of care, that is gonna continue to support the marketplace.
Eric: So the marketplace is doing okay?
Mike: The marketplace is thriving.
Eric: What about the other side of this? This has implications for the residents, for staff, between the age demographics and immigration. What is happening on the other side of this?
Mike: I gotta tell you, I give full credit to Mark Parkinson for sharing all this. The biggest challenge we face is finding staff to work in post-acute and long-term care. The number of younger people to older continues to drop, and we’re seeing the immigration piece.
Anyone who’s ever worked in a nursing home knows the percentage of staff who come from other countries, whether it be the Philippines, Africa, you name it.
“If you’ve seen one post-acute long-term care resident, you’ve seen one post-acute long-term care resident. They all have their individual needs. You have to determine what they are.”
—Dr. Mike Wasserman
Eric: From when you were an executive, what would be a sign of a healthy amount of staff, and what would be a sign or a symptom of low staffing?
Mike: I was the CEO overseeing a nursing home chain, which means I needed to have certainly an understanding of the administrator’s role.
Staffing has always been key. In fact, one of the things I did during my tenure as CEO was to get our directors of nursing and clinical folks together to develop better systems to determine appropriate acuity-based staffing.
And I think that is what it comes down to, which is why I am a huge advocate for and fan of the latest addition to the rules of participation that really go into an effective facility assessment. In some regards, honing in on requiring really good facility assessments and holding facilities to them could be more powerful than a minimum staffing requirement.
Eric: What would that look like?
Mike: If you’re doing a good facility assessment, the director of nursing needs to work with their medical director, they need to work with their staff, they need to work with their governing body, they need to work with families and residents to look at: what is our acuity, and what does it take to provide quality care to the residents?
There’s a great paper that Mary Ellen Dellefield, Charlene Harrington, and others put out that really walks facility leadership through this.
This is not an unknown. This is not a black box. Facilities should be able to determine what level of staff they need.
And one thing we do know: if a facility is understaffed, whether it’s that you don’t have an RN 24/7, whether you have one CNA for 20 residents, you’re gonna have poorer quality of care.
Eric: So in the case of resident acuity, what would be an example of a low-acuity resident and a high-acuity resident, and what kind of care each of them might need?
Mike: You can look at a skilled resident who requires IV therapies, requires constant monitoring, requires turning regularly, versus a more custodial resident who maybe has some cognitive impairment and requires that sort of attention but is ambulatory.
At the end of the day, there is an individualized nature that’s needed, because if you’ve seen one post-acute long-term care resident, you’ve seen one post-acute long-term care resident. They all have their individual needs. You have to determine what they are.
I will say, I stay out of this discussion often because of the importance of RN and CNA needs, but there are other folks like social workers and activities folks and restorative folks that are also highly critical to providing the right kind of care.
Eric: And I’ll throw in medical directors, given the paper we co-wrote a couple years ago.
Mike: I always advocate — I believe that certified, competent, and engaged medical directors are the ultimate oversight modality. The eyes and ears of a medical director who’s been in nursing homes and has that experience is absolutely invaluable.
Eric: So you pride yourself as being nonpartisan, independent in a lot of places. In the nursing home long-term care policy world, there’s tension between different stakeholders. As with everything, there’s some bad actors, but there are some people with good intentions who happen to have differing perspectives and ideas.
Can you describe what that main battle might be, if there’s two camps there?
Mike: Absolutely. It’s interesting. Several years ago, a New York Times reporter described me as a critic of the nursing home industry. Knowing that she was gonna say that, I called and said, “You really have to call me back.” And they didn’t back down.
Once it was published, I actually thought about it, and I ultimately wrote a column in McKnight’s acknowledging I am a critic of the nursing home industry, but at the same time, I am a fierce advocate and supporter for the nursing home profession.
The bottom line is there’s a lot of money that the federal government spends on nursing homes, but a not insignificant amount of that money ends up outside of nursing home operations, whether it be high profits for the real estate the nursing home’s sitting on, maybe the staffing agency that supplies the nursing home, or the supply company that supplies the nursing home.
If you start pulling out excess profits into all those places, there’s not a lot left to take care of the residents. That’s where I am a critic of the industry/financial structure of the nursing home industry.
Eric: A couple rapid-fire questions: First, what would you say is the blind spot of the nursing home industry?
Mike: The blind spot of the nursing home industry is actually the importance of quality.
Eric: Blind spot of the advocacy community?
Mike: The blind spot of the advocacy industry is common sense of what actually can occur in Congress.
Eric: Feasibility would be a word in this environment.
Mike: Yeah.
Eric: And a bonus question: what’s your own blind spot?
Mike: My own blind spot is I can be too trusting.
Eric: Well, thanks for trusting me with those questions.
Eric: We’re gonna pivot to fitness, running, biking, swimming. Three weeks ago you did a half Ironman which I learned is, what, 70.3 combined miles. Is your body recovered? Are you already thinking about the next one?
Mike: So the funny thing is, I am three weeks out from that half Ironman, and I actually did a half marathon yesterday. There is something after a race like that called supercompensation. If you time it right, you don’t overdo it, you don’t push too hard on your fatigue, you let your body recover, it is amazing what happens to your body.
So I ran a half marathon yesterday in preparation for racing a half marathon in two more weeks.
The other thing I continue to learn: it’s not just the time you spend running, biking, and swimming. If you’re in meetings all day, if your cortisol is up from stress, that all has an impact on you.
The positive is I feel fantastic today other than just being a little tired from doing a half marathon yesterday, and in two weeks we’ll see. I’m hoping to have my fastest half-marathon time in quite a while.
“The toll that training and racing an Ironman has on the human body is significant, and I think there is a point in time that it can be too much. It could break you down.”
—Dr. Mike Wasserman
Eric: You said something to me about a year ago that was actually a little contrary to what I thought you were gonna say.
You were talking about how there’s this idea that exercise keeps you, air quote, “younger,” but you also made the point that our body does have finite resources. And if you’re spending them running, biking, swimming 70 miles, doing another half marathon three weeks later, that comes at a cost.
Can you talk about the concept of that toll that it takes on your body?
Mike: Since I’m retired now, ironically, I look at the toll, say, my meeting took on my racing, rather than vice versa.
But the flip side of that is if you’re working full time, you’ve got a family, and you’re also training, there’s a toll in both directions. And I think a lot of us don’t really appreciate the stress that work puts on us. The cortisol spikes from stress — that can affect your training and racing as well. So it goes in both directions.
I did my last full Ironman four years ago in St. George, Utah, and had a great swim — one of my best swims in a decade — felt fantastic two hours into the bike, and that’s when I decided that this would be my last Ironman.
I decided that for two reasons. One is I’m 66, soon to be 67. I love Ironmans. I could complete an Ironman. I have no doubt about it. But the toll that training and racing an Ironman has on the human body is significant, and I think there is a point in time that it can be too much. It could break you down and create problems.
So the reason I made the decision two hours into the bike was everyone finishes a marathon or an Ironman almost guaranteed to say, “I’m never doing this again.” But you never can believe yourself. This time I made the decision when I felt great, and I made it for the right reason.
There’s a lot of interesting stuff as we age that I continue to learn. I think you’ll see on LinkedIn I’ve really started talking a lot more about my training, not to say to people, “Oh, I’m 66 and I’m doing this,” but more to say, “Look what older people can do if we’re smart about it.”
There is the “use it or lose it” idea as we get older, whether it’s mental or physical, it is very true. You gotta stay active. You gotta stay lubricated. You gotta keep moving your body. And I think daily exercise of some sort is really invaluable as we get older.
Eric: Are there elements of your fitness journey as an older adult that you have used either directly or indirectly in your advocacy?
Mike: I think the thing that is helping me in both spaces is learning how to be more thoughtful and meditative.
I always like to say that life is an Ironman, and my coach has always said, “The key thing to doing an Ironman is staying in the moment the entire race.” You never want to look back and say, “Damn, I should’ve swam better,” or, “Oh my gosh, I’m worried about the run coming up.”
You need to be in the moment appreciating what you’re doing, avoiding negativity, being present.
And I find that in my work life — and even though I’m retired, I do a lot of volunteer work and advocacy work — staying present and curious is absolutely essential to balance and mental health. So I think that’s where life imitates exercise and training and things like that.
Eric: And was there a moment in that 70.3 where you were thinking about that?
Mike: I have to say, even though the half Ironman in New Zealand is a gorgeous race, the people are wonderful, it turned out to be one of the most miserable races I’ve ever had, despite all my efforts to not think about that.
It was hard because I was so cold on the bike that I was literally shivering, and I did the entire run with pretty significant back spasms. But again, while I would say it was miserable, mentally throughout most of it I was not thinking that. Because if I thought that, I would’ve stopped.
So you basically find a place for your brain to be that is positive, that is thoughtful, that is curious, and you just gotta go there.
The 3:20
Eric: We’re gonna close this out with, we’ll call this The 3:20. It’s gonna be three minutes and 20 seconds of rapid-fire questions. And I will start the clock in five, four, three, two, one.
Best temperature for workouts?
Mike: Sixty degrees.
Best temperature for walking outside?
Mike: Sixty-five degrees.
Okay, 65. Now, you’re not in New Zealand now, but how did you end up there?
Mike: Both my daughters and my grandchildren moved there, and I’m retired.
And how did they end up there?
Mike: In 2009, my daughter, on a vacation to New Zealand with the family, met her future husband, and they decided to move back.
Favorite U.S. president?
Mike: Abraham Lincoln.
What is your go-to AI tool?
Mike: Right now it’s ChatGPT, but because I find it to be both lazy and not honest, I’m looking for others. It’s been suggested I try Claude.
What are your running sneakers?
Mike: Hokas.
For races also?
Mike: Yes.
And what’s your running watch?
Mike: A Garmin.
What is your favorite running stat or running indicator?
Mike: Right now it’s cadence.
What’s your cadence?
Mike: Actually, depends on how fast, what the race is. But for a 5K, I’m looking at like 175. For my half marathon yesterday, I was looking between 170 and 175.
Most overrated running stat or indicator?
Mike: Pace.
Favorite nursing home stat or indicator?
Mike: Turnover. Staff turnover.
And why is that?
Mike: Because it’s an indicator of quality and also leadership.
Even the CMS turnover metric?
Mike: Well, I don’t know.
Okay. Most overrated nursing home stat or indicator?
Mike: Readmissions.
Why is that?
Mike: I don’t know. That’s what just came to mind.
Coffee order?
Mike: An oat milk latte.
What book are you reading?
Mike: Zionism at the Ends of the Earth.
And what show are you watching?
Mike: Oh my gosh. Right now, actually, my kids got me watching The Vow.
And what is the best medical show or movie?
Mike: You know what? I’m gonna go retro: Marcus Welby, M.D.
Final question. We got 20 seconds. A tip for your 36-year-old self?
Mike: Learn to chill a little bit and modulate your passion.
Eric: Okay, great. Well, I selfishly ask that. I’m turning 36 in a few days, so I appreciate that tip. And thanks for coming on here.
Mike: I love your format, and I actually just enjoyed the 360. That was a lot of fun.
Eric: The 320!
Produced by Dalton Miksa.
